Repair of orbital floor fractures using bioresorbable poly-L/DL-lactide plates

To assess the long-term clinical and radiologic findings after insertion of a bioresorbable polylactide plates P(L/DL)LA 70/30 implant (PolyMax) in the repair of orbital floor and wall defects, with special focus on stability and clinical signs of foreign-body reaction.

Pentalogy or hexalogy of Cantrell?

Pentalogy of Cantrell (PC) is a rare congenital syndrome involving the abdominal wall, sternum, diaphragm, pericardium, and heart. The embryonic period in which PC develops coincides with that of umbilical cord (UC) formation. The aim of the following study was to address the question of whether PC is associated with UC pathologies. Four cases, prenatally identified between 2002 and 2008, were enrolled in this study. Umbilical cord pathologies defined as single umbilical artery, short cord, or UC with atypical coiling pattern were retrospectively assessed on stored ultrasound images and from autopsy reports. The literature regarding PC and UC pathologies was reviewed. Three singleton pregnancies and 1 monoamniotic twin pregnancy with twin reversed arterial perfusion sequence were reviewed. All had a normal karyotype. Three showed the classical PC stigmata, with ectopia cordis. One fetus had no ectopia cordis; this case had a normal UC, whereas all others fetuses showed a short UC with atypical coiling pattern. Of 26 publications dealing with PC, the UC was described in only 8 cases, 7 of which were abnormal. There seems to be a strong correlation between the PC and UC abnormalities, in particular in cases with ectopia cordis. We speculate that the insult leading to the classical malformations of PC and UC abnormalities is the same or the sequence of malformations itself may alter the early fetoplacental blood flow and therefore the normal development of the UC angioarchitecture.

Evaluation of respiratory parameters at presentation as clinical indicators of the respiratory localization in dogs and cats with respiratory distress

OBJECTIVE: To describe clinical respiratory parameters in cats and dogs with respiratory distress and identify associations between respiratory signs at presentation and localization of the disease with particular evaluation between the synchrony of abdominal and chest wall movements as a clinical indicators for pleural space disease. Design - Prospective observational clinical study. SETTING: Emergency service in a university veterinary teaching hospital. ANIMALS: Cats and dogs with respiratory distress presented to the emergency service between April 2008 and July 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The following parameters were systematically determined at time of admission: respiratory rate, heart rate, temperature, type of breathing, movement of the thoracic and abdominal wall during inspiration, presence of stridor, presence and type of dyspnea, and results of thoracic auscultation. Abdominal and chest wall movement was categorized as synchronous, asynchronous, or inverse. Diagnostic test results, diagnosis, and outcome were subsequently recorded. Based on the final diagnoses, animals were assigned to 1 or more of the following groups regarding the anatomical localization of the respiratory distress: upper airways, lower airways, lung parenchyma, pleural space, thoracic wall, nonrespiratory causes, and normal animals. One hundred and seventy-six animals (103 cats and 73 dogs) were evaluated. Inspiratory dyspnea was associated with upper airway disease in dogs and expiratory dyspnea with lower airway disease in cats. Respiratory noises were significantly associated and highly sensitive and specific for upper airway disease. An asynchronous or inverse breathing pattern and decreased lung auscultation results were significantly associated with pleural space disease in both dogs and cats (P<0.001). The combination is highly sensitive (99%) but not very specific (45%). Fast and shallow breathing was not associated with pleural space disease. Increased or moist pulmonary auscultation findings were associated with parenchymal lung disease. CONCLUSIONS: Cats and dogs with pleural space disease can be identified by an asynchronous or inverse breathing pattern in combination with decreased lung sounds on auscultation.

[Rumenocentesis: a suitable technique for analysis of rumen juice pH in cattle?]

In the United States, rumenocentesis has been recommended especially for early diagnosis of subacute rumen acidosis (SARA). The objective of the current study was to evaluate health risks due to the technique ofrumenocentesis and to measure pH in ruminal juice using a commercial indicator paper (Pehanon) and a pH electrode (reference method). After 11 dairy cows underwent rumenocentesis, the clinical status of those animals was evaluated daily, and cows were slaughtered as well as pathologically--anatomically examined on day 7. During the observation period, the following pathological clinical signs were evident: forced inspiration (3 cows), transient episode of hyperthermia (2 cows), increased tension of the abdominal wall (8 cows) and positive foreign body tests (3 cows). One cow had to be culled on day 7 because of severe generalised septic peritonitis spreading from the site of rumenocentesis. At slaughter, hematoma formation in the area of the puncture site was found in 9 out of 10 cows. It was concluded that the severe complications encountered with this technique do not legitimate rumenocentesis as a routine procedure for collection of rumen juice samples in cows under Swiss conditions. The correlation between the pH reference method and the commercial indicator paper was the high (r = 0.926).

The polytraumatized or multiply injured child

10.1 In the severely injured infant and child the following age-specific facts should be kept in mind: ■ Larger head to body weight ratio (head often exposed to injury, neck injury) ■ Larger body surface area to body volume ratio (hypothermia) ■ More elastic thoracic wall (internal injury possible without external signs) ■ Thinner abdominal wall where abdominal organs are below the rib cage (liver, spleen injury) ■ Smaller total blood volume ■ Narrow airways ■ Long compensation of blood loss by tachycardia followed by rapid decompensation of circulatory status if left untreated 10.2 Child abuse is frequent: about 3%–7% of children under 18 years suffer from child abuse in some manner. The incidence and prevalence depend on the development of a country’s social service agencies and on the level of health professionals’ awareness of the problem. The estimated number of unreported cases is high. Child abuse affects children of all socioeconomic, ethnic, and religious boundaries. There is no gender preponderance. It occurs at any age, but infants and toddler have a higher risk than older children.

The umbilical cord in Cantrell: Pentalogy or Hexalogy?

Objective: Pentalogy of Cantrell (PC) is a rare congenital defect associated with five midline anomalies. The type of cardiac malformation and the size of the abdominal wall defect is often responsible for the high mortality. Of interest, the embryonic period in which PC develops is similar to that of the umbilical cord’s (UC) formation. The aim of the following study was to investigate the relationship between UC anomalies and PC. Methods: Charts of four cases with PC from 2002–08 were retrospectively reviewed for associated UC anomalies. UC anomalies were defined as single umbilical artery (SUA), short cord (during 1st trimester less than CRL or less than 30cm at term) or atypical UC coiling pattern. Results: We identified four cases: 3 singletons and one monochorionic diamniotic twin pregnancy with TRAP sequence. All cases showed a normal karyotype. All but one demonstrated the classical pulsatile omphalocele with ectopia cordis and all others anomalies of PC. One case was characterized by a major cranial omphalocele without ectopia cordis and no UC anomaly. This fetus was delivered by Cesarean at term and successfully operated on d1. In all other cases the parents requested ToP. Among the three cases with ectopia cordis, two had a short UC with SUA and one a short three-vessel cord; all these three UC were markedly uncoiled. Conclusions: Our data suggest a strong association between Cantrell and the development of the UC, in particular in cases with ectopia cordis. One might speculate that hemodynamic alterations of the feto-placental blood flow because of the cardiac malformation or structural changes at the umbilical ring (omphalocele) influence the development of the UC. More observations are needed to decide if Cantrell is a ‘‘hexalogy’’ instead of pentalogy.

Implantation of Prophylactic Nonabsorbable Intraperitoneal Mesh in Patients With Peritonitis Is Safe and Feasible

BACKGROUND: Patients with peritonitis undergoing emergency laparotomy are at increased risk for postoperative open abdomen and incisional hernia. This study aimed to evaluate the outcome of prophylactic intraperitoneal mesh implantation compared with conventional abdominal wall closure in patients with peritonitis undergoing emergency laparotomy. METHOD: A matched case-control study was performed. To analyze a high-risk population for incisional hernia formation, only patients with at least two of the following risk factors were included: male sex, body mass index (BMI) >25 kg/m(2), malignant tumor, or previous abdominal incision. In 63 patients with peritonitis, a prophylactic nonabsorbable mesh was implanted intraperitoneally between 2005 and 2010. These patients were compared with 70 patients with the same risk factors and peritonitis undergoing emergency laparotomy over a 1-year period (2008) who underwent conventional abdominal closure without mesh implantation. RESULTS: Demographic parameters, including sex, age, BMI, grade of intraabdominal infection, and operating time were comparable in the two groups. Incidence of surgical site infections (SSIs) was not different between groups (61.9 vs. 60.3 %; p = 0.603). Enterocutaneous fistula occurred in three patients in the mesh group (4.8 %) and in two patients in the control group (2.9 %; p = 0.667). The incidence of incisional hernia was significantly lower in the mesh group (2/63 patients) than in the control group (20/70 patients) (3.2 vs. 28.6 %; p < 0.001). CONCLUSIONS: Prophylactic intraperitoneal mesh can be safely implanted in patients with peritonitis. It significantly reduces the incidence of incisional hernia. The incidences of SSI and enterocutaneous fistula formation were similar to those seen with conventional abdominal closure.

Allograft Survival with Calcineurin Inhibitors

The immunosuppressive drugs cyclosporine A (CsA) and tacrolimus (FK506), also called calcineurin inhibitors, have truly revolutionized allograft transplantation. The introduction of CsA in 1976 was the first major advance in transplantation since the introduction of prednisone and azathioprine made allograft transplantation possible in the early 1950s and 1960s. FK506 was approved in 1994 and led to dramatic improvements in solid organ transplantation, allowing highly antigenic lymph node bearing allografts, such as the small bowel, to be transplanted. Recently, FK506 monotherapy has successfully allowed combined small bowel and partial abdominal wall transplantation in humans. The success of FK506 and CsA has made them key drugs in the modern era of transplantation. The purine synthesis inhibitor mycophenolate mofetil (MMF) was approved in 1995, and the drug Sirolimus (rapamycin) was introduced in 1999. Combining these drugs with calcineurin inhibitors has significantly reduced the incidence of acute rejection and improved solid organ allograft survival, with a reduction in adverse effects.

Towards clinical computed ultrasound tomography in echo-mode: Dynamic range artefact reduction

Computed ultrasound tomography in echo-mode (CUTE) allows imaging the speed of sound inside tissue using hand-held pulse-echo ultrasound. This technique is based on measuring the changing local phase of beamformed echoes when changing the transmit beam steering angle. Phantom results have shown a spatial resolution and contrast that could qualify CUTE as a promising novel diagnostic modality in combination with B-mode ultrasound. Unfortunately, the large intensity range of several tens of dB that is encountered in clinical images poses difficulties to echo phase tracking and results in severe artefacts. In this paper we propose a modification to the original technique by which more robust echo tracking can be achieved, and we demonstrate in phantom experiments that dynamic range artefacts are largely eliminated. Dynamic range artefact reduction also allowed for the first time a clinical implementation of CUTE with sufficient contrast to reproducibly distinguish the different speed of sound in different tissue layers of the abdominal wall and the neck.

Gastroesophageal intussusception in a leopard (Panthera pardus).

An 8-yr-old male leopard (Panthera pardus) was presented with a 4-day history of lethargy, vomiting, and anorexia. Thoracic and abdominal radiographs revealed a soft-tissue mass cranial to the diaphragm and atypical appearance of the gastric fundus. Esophagoscopy revealed gastric mucosa in the lumen of the esophagus, which confirmed gastroesophageal intussusception. An exploratory celiotomy with manual reduction of the intussusception was performed. Reduction was verified by intraoperative esophagoscopy and gastroscopy. An incisional fundic gastropexy to the left abdominal wall was performed to reduce the chance of a recurrence of the intussusception. No postoperative complications related to the surgery were observed, and the animal resumed eating within 48 hr of surgery. A subsequent recurrence of clinical signs was not noted by the owner.

Severe postoperative wound healing disturbance in a patient with alpha-1-antitrypsin deficiency: the impact of augmentation therapy

Wound healing disturbance is a common complication following surgery, but the underlying cause sometimes remains elusive. A 50-year-old Caucasian male developed an initially misunderstood severe wound healing disturbance following colon and abdominal wall surgery. An untreated alpha-1-antitrypsin (AAT) deficiency in the patient's medical history, known since 20 years and clinically apparent as a mild to moderate chronic obstructive pulmonary disease, was eventually found to be at its origin. Further clinical work-up showed AAT serum levels below 30% of the lower reference value; phenotype testing showed a ZZ phenotype and a biopsy taken from the wound area showed the characteristic, disease-related histological pattern of necrotising panniculitits. Augmentation therapy with plasma AAT was initiated and within a few weeks, rapid and adequate would healing was observed. AAT deficiency is an uncommon but clinically significant, possible cause of wound healing disturbances. An augmentation therapy ought to be considered in affected patients during the perioperative period.

Healing of two and three wall intrabony periodontal defects following treatment with an enamel matrix derivative combined with autogenous bone

BACKGROUND: There are still limited data on the outcomes of regenerative periodontal surgery using a combination of an enamel matrix protein derivative (EMD) and autogenous bone (AB). AIM: To evaluate the healing of deep intrabony defects treated with either a combination EMD+AB or EMD alone. MATERIALS AND METHODS: Forty patients with advanced chronic periodontitis, with one deep intrabony defect, were randomly treated with either EMD+AB (test) or EMD (control). Clinical assessments were performed at baseline and at 1 year after treatment. The primary outcome variable was relative attachment level (RAL). RESULTS: Healing was uneventful in all patients. The test sites showed a reduction in the mean probing pocket depth (PPD) of 5.6 +/- 0.9 mm (p<0.001), a gain in the mean RAL of 4.2 +/- 1.1 mm (p<0.001) and a gain in the mean probing bone level (PBL) of 3.9 +/- 1.0 mm (p<0.001). The control group displayed a mean PPD reduction of 4.6 +/- 0.4 mm (p<0.001), a mean RAL gain of 3.4 +/- 0.8 mm (p<0.001) and a mean PBL gain of 2.8 +/- 0.8 mm (p<0.001). RAL gains of > or =4 mm were measured in 90% of the test defects and in 55% of the controls. PBL gains of > or =4 mm were obtained in 85% of the test defects and in 25% of the control ones. The test treatment resulted in statistically higher PPD reductions, RAL gains and PBL gains compared with the control (p<0.01). CONCLUSIONS: Within their limits, the present results indicate that: (i) at 1 year after surgery, both therapies resulted in statistically significant clinical improvements compared with baseline and (ii) although the combination of EMD+AB resulted in statistically significant higher soft and hard tissue improvements compared with treatment with EMD, the clinical relevance of this finding is unclear.

How should bladder wall thickness be measured? A comparison of vaginal, perineal and abdominal ultrasound

Measurement of bladder wall thickness using transvaginal ultrasound has previously been shown to discriminate between women with diagnosed detrusor overactivity and those with urodynamic stress incontinence. So far, no comparison has been made between abdominal, perineal and vaginal route for the measurement of bladder wall thickness. The aim of this prospective study was to determine if abdominal, perineal and vaginal ultrasound measurements of bladder wall thickness are comparable with each other.